Inquiry finds 450 lives shortened by hospital regime of administering opioids

An “institutionalised regime” of prescribing and administering opioids without medical justification at the Gosport War Memorial Hospital shortened the lives of more than 450 people, an inquiry has found.

An additional 200 patients were “probably” similarly affected between 1989 and 2000, when taking into account missing records, according to a report by the Gosport Independent Panel.

Hospital management, Hampshire Police, the Crown Prosecution Service (CPS), General Medical Council (GMC) and Nursing and Midwifery Council (NMC) “all failed to act in ways that would have better protected patients and relatives”, the panel said.

Its report also highlighted failings by healthcare organisations, local politicians and the coronial system.

The Gosport Independent Panel investigation into hundreds of suspicious deaths at the hospital, which was first launched in 2014, examined more than one million pages.

It revealed “there was a disregard for human life and a culture of shortening lives of a large number of patients” at the Hampshire hospital.

The report added: “There was an institutionalised regime of prescribing and administering ‘dangerous doses’ of a hazardous combination of medication not clinically indicated or justified, with patients and relatives powerless in their relationship with professional staff.”

When relatives complained or raised concerns, they were “consistently let down by those in authority – both individuals and institutions”.

The report concludes: “The panel found evidence of opioid use without appropriate clinical indication in 456 patients.

“The panel concludes that, taking into account missing records, there were probably at least another 200 patients similarly affected but whose clinical notes were not found.

“The panel’s analysis therefore demonstrates that the lives of over 450 people were shortened as a direct result of the pattern of prescribing and administering opioids that had become the norm at the hospital, and that probably at least another 200 patients were similarly affected.”

The panel found that, over a 12-year period as clinical assistant, Dr Jane Barton was “responsible for the practice of prescribing which prevailed on the wards”.

In 2010, the GMC ruled that Dr Barton, who has since retired, was guilty of multiple instances of professional misconduct relating to 12 patients who died at the hospital.

Nurses on the ward were not responsible for the practice but did administer the drugs, including via syringe drivers, and failed to challenge prescribing, the panel said.

Consultants, though not directly involved in treating patients on the ward, “were aware” of how drugs were administered but “did not intervene to stop the practice”.

The inquiry, led by the former bishop of Liverpool, the Rt Rev James Jones, did not ascribe criminal or civil liability for the deaths.

However it said: “The Secretary of State for Health and Social Care and the relevant public authorities will want to consider the action that now needs to be taken to further investigate what happened at the hospital.

“The Secretary of State will want to ensure that families who believe they were affected by events at the hospital have the support they deserve going forward, and also to consider wider lessons.”

Health Secretary Jeremy Hunt is due to address MPs on the findings of the Gosport inquiry later, and will face questions about the previous investigations and whether charges should now be brought.

Campaigners have called for tough action following the publication of the report.

How events unfolded in hospital deaths probe

Campaigners have called for prosecutions to follow the publication of a major report into suspicious deaths at Gosport War Memorial Hospital.

The Gosport Independent Panel inquiry was established in 2014 to address concerns about the deaths of a number of elderly patients at the hospital in Hampshire between 1988 and 2000.

Here is a timeline of events.

• August 1998 – Gladys Richards dies in Gosport War Memorial Hospital after going in for rehabilitation following a hip operation. Her family report concerns about her treatment to the police and the coroner.
• 2001 – In the three years after Mrs Richards’ family came forward, three more went to police and two more case were reported to the NHS ombudsman.
• July 2002 – The Commission for Health Improvement (CHI) criticised Portsmouth Healthcare NHS Trust, which ran the hospital, for excessive use of pain relief and sedative drugs.
• February 2005 – Hampshire Police detectives pass files of evidence to the Crown Prosecution Service (CPS) about the deaths of elderly patients.
• December 2006 – Hampshire Police announces that no-one would face prosecution over the deaths of patients at the hospital after a four-year inquiry. The CPS says that negligence could not be proven to a criminal standard and that there was no realistic prospect of conviction of healthcare staff.
• April 2009 – An inquest jury rules drugs given to five elderly people at the hospital contributed to their deaths.
• January 2010 – The General Medical Council finds Dr Jane Barton (pictured in 2009) guilty of serious professional misconduct by a Fitness to Practise Panel. The panel found she made a catalogue of failings in her treatment of the patients, who later died, including issuing drugs which were “excessive, inappropriate and potentially hazardous”. Instead of being struck off she was given a list of 11 conditions relating to her practice, including not being able to administer opiates by injection.
• March – Dr Barton retires from medical practice.
• August – The CPS announces that no criminal charges are to be brought against Dr Barton after finding there is insufficient evidence to mount a prosecution for gross negligence manslaughter in 10 key cases.
• September – Ann Reeves, the daughter of 88-year-old Elsie Devine, leads a protest march to Downing Street.
• April 2013 – A coroner rules that medication given to Mrs Richards contributed “more than insignificantly” to her death.
• July 2014 – An independent investigation into more than 90 deaths at the hospital is launched by health minister Norman Lamb and was due to conclude in 2017.
• 2016 – The inquiry is extended and its publication date is put back to 2018.
• June 20 2018 – The inquiry is published.

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